Dependent Personality Disorder

The Dependent Personality Disorder is characterized by a pervasive pattern of dependent and submissive behaviors. Sufferers of this disorder are excessively passive, insecure, and isolated individuals who become abnormally dependent on one or more persons.

While initially acceptable, this dependent behavior can become controlling, appear hostile, and even blend into a passive-aggressive pattern.

This disorder is more common in females (2:1 females to males). In females the dependent style often takes the form of submissiveness, while in males the dependent style is more likely to be autocratic, such as when the husband and boss depends on his wife and secretary to perform essential tasks which he himself cannot accomplish. In either case, this disorder is likely to lead to anxietyOpens in new window and depressionOpens in new window when the dependent relationship is threatened.

Clinical Presentation

The clinical presentation of the Dependent Personality Disorder can be described in terms of behavioral and interpersonal style, thinking style, and feeling style. Dependent personalities’ behavioral and interpersonal styles are characterized by docility, passivity, and non-assertiveness.

In interpersonal relations, they tend to be pleasing, self-sacrificing, clinging, and constantly requiring the assurance of others. Their compliance and reliance on others lead to a subtle demand that others assume responsibility for major areas of their lives.

The thinking or cognitive style of dependent personalities is characterized by suggestibility. They easily adopt a Pollyannaish attitudeOpens in new window toward life. Furthermore, they tend to minimize difficulties, and because of their naiveté, are easily persuadable and easily taken advantage of. In short, this style of thinking is uncritical and unperceptive.

Their feeling or affective style is characterized by insecurity and anxiousness. Because they lack self-confidence, they experience considerable discomfort at being alone. They tend to be preoccupied with the fear of abandonment and disapproval of others. Their mood tends to be one of anxietyOpens in new window or fearfulnessOpens in new window, as well as having a somber or sad quality.

DSM-5 Characterization

Individuals with this personality disorder are characterized by an excessive and unremitting need to be cared for, and cling to others because of their fear of separation. They constantly seek the advice and reassurance of others when making decisions.

More than anything, they want others to take responsibility for most major areas of their lives. Not surprisingly, they seldom express disagreement with others for fear they will lose their support and approval. Because they lack confidence in their own judgment and ability, they have difficulty starting projects and doing things on their own. These individuals will even engage in actions that are difficult and unpleasant in order to receive support and caring from others.

Because of unrealistic fears of being unable to take care of themselves, they feel helpless or uncomfortable when faced with being alone. When a close relationship is about to end, they immediately seek out another caring and supportive relationship. Finally, they become preoccupied with fears of being left to take care of themselves (American Psychiatric Association, 2013).

Case Example: Ms. D.
Ms. D. is a 34-year-old single, white female with a two-year history of partially treated panic attacks. Her panic symptoms began approximately three years previously and consisted of symptoms of hyperventilation, palpitations, lightheadedness, and a feeling of dread while she was working around her apartment. Because she believed she was having a heart attack, she called for an ambulance and was taken to the emergency room of a local hospital. A heart attack was ruled out and she was referred to her primary care physician to be treated for anxiety symptoms. Over the course of the next several months, she was treated with Valium and the physician insisted she get psychotherapy. She did not, however, follow up with the recommendation for psychotherapy until 19 months after her first symptoms continued, and because of anticipatory anxiety of further panic attacks, she became increasingly homebound and agoraphobic. Over this period of time she became more moody, irritable, fatigued, and tearful, and she had difficulty with initial insomnia as well as early morning awakening. Ms. D. is the younger of two siblings. Her brother was described as a successful attorney. Her parents were both alive, and since the panic attacks had begun, she moved back into her parents’ home. She decribed both her parents as caring, concerned, and “my best friends.” Ms. D. had graduated from college and went on to complete a master’s degree in education. Subsequently, she worked for four years as an elementary school teacher before her first symptoms occurred. Since then she had taken an indefinite leave of absence from her job. She reported being sickly as a young child and being taken by mother from doctor to doctor for various minor ailments. Even though she was a good student at school and had some friends, she preferred to come home after school and help Mother around the house with the house cleaning and chores. The following early recollections were reported: At age six she remembers her first day of going to school by herself. “I was proud. My mother said I could walk to school by myself. But when I turned the corner, I saw her out of the corner of my eye, following me.” She recalls looking over her shoulder and seeing her mother behind a tree, and feeling flustered and angry, and at the same time relieved that her mother was there. She remembers thinking, “Why can’t she let me do this by myself?” She remembers at age four getting her first puppy. “It was a mixed collie and a shepherd. Little Fluffy couldn’t make it down the driveway on its own. When I tried to take him for a walk his legs just collapsed and he began to pant. So Fluffy became dependent on everyone. I had to pick him up and I said, ‘He’s too tired to do it by himself.’” She recalls bending down and picking up her dog and thinking “He’s too tired,” and feeling love for her puppy, and love and appreciation from him. At age five she recalls her mother asking her to go to the corner store to get some stamps. “She gave me instructions on how to cross the street, get change from the cashier, and put the money in the stamp machine. But when I went over to the stamp machine, I couldn’t reach the coin slot because it was too high off the ground.” Ms. D. recalls standing in front of the machine and trying to get it to work, but not being able to reach the coin slot, and feeling puzzled and nervous, wondering if someone would see her and try to help her. Ms. D.’s presenting symptoms, her early childhood and family history, and her early recollections are all suggestive of the clinical presentation and dynamics of the Dependent Personality Disorder. Not only was Ms. D. overly dependent on her parents, she also became quite dependent on the Valium that she was prescribed for panic symptoms. The case of Ms. D. is prototype of many individuals who present with panicOpens in new window, agoraphobicOpens in new window, and depressiveOpens in new window features. That is, the Dependent Personality Disorder is the most common personality disorder in individuals presenting with panic and agoraphobic symptoms.

Case Example: Ms. D.

Ms. D. is a 34-year-old single, white female with a two-year history of partially treated panic attacks. Her panic symptoms began approximately three years previously and consisted of symptoms of hyperventilation, palpitations, lightheadedness, and a feeling of dread while she was working around her apartment. Because she believed she was having a heart attack, she called for an ambulance and was taken to the emergency room of a local hospital. A heart attack was ruled out and she was referred to her primary care physician to be treated for anxiety symptoms.

Over the course of the next several months, she was treated with Valium and the physician insisted she get psychotherapy. She did not, however, follow up with the recommendation for psychotherapy until 19 months after her first symptoms continued, and because of anticipatory anxiety of further panic attacks, she became increasingly homebound and agoraphobic. Over this period of time she became more moody, irritable, fatigued, and tearful, and she had difficulty with initial insomnia as well as early morning awakening.

Ms. D. is the younger of two siblings. Her brother was described as a successful attorney. Her parents were both alive, and since the panic attacks had begun, she moved back into her parents’ home. She decribed both her parents as caring, concerned, and “my best friends.” Ms. D. had graduated from college and went on to complete a master’s degree in education. Subsequently, she worked for four years as an elementary school teacher before her first symptoms occurred. Since then she had taken an indefinite leave of absence from her job. She reported being sickly as a young child and being taken by mother from doctor to doctor for various minor ailments. Even though she was a good student at school and had some friends, she preferred to come home after school and help Mother around the house with the house cleaning and chores.

The following early recollections were reported: At age six she remembers her first day of going to school by herself. “I was proud. My mother said I could walk to school by myself. But when I turned the corner, I saw her out of the corner of my eye, following me.” She recalls looking over her shoulder and seeing her mother behind a tree, and feeling flustered and angry, and at the same time relieved that her mother was there. She remembers thinking, “Why can’t she let me do this by myself?”

She remembers at age four getting her first puppy. “It was a mixed collie and a shepherd. Little Fluffy couldn’t make it down the driveway on its own. When I tried to take him for a walk his legs just collapsed and he began to pant. So Fluffy became dependent on everyone. I had to pick him up and I said, ‘He’s too tired to do it by himself.’” She recalls bending down and picking up her dog and thinking “He’s too tired,” and feeling love for her puppy, and love and appreciation from him.

At age five she recalls her mother asking her to go to the corner store to get some stamps. “She gave me instructions on how to cross the street, get change from the cashier, and put the money in the stamp machine. But when I went over to the stamp machine, I couldn’t reach the coin slot because it was too high off the ground.” Ms. D. recalls standing in front of the machine and trying to get it to work, but not being able to reach the coin slot, and feeling puzzled and nervous, wondering if someone would see her and try to help her.

Ms. D.’s presenting symptoms, her early childhood and family history, and her early recollections are all suggestive of the clinical presentation and dynamics of the Dependent Personality Disorder. Not only was Ms. D. overly dependent on her parents, she also became quite dependent on the Valium that she was prescribed for panic symptoms. The case of Ms. D. is prototype of many individuals who present with panic, agoraphobic, and depressive features. That is, the Dependent Personality Disorder is the most common personality disorder in individuals presenting with panic and agoraphobic symptoms.

Biopsychosocial – Adlerian Conceptualization

The following biopsychosocial formulation may be helpful in understanding how the Dependent Personality Disorder is likely to have developed. Biologically, these individuals are characterized by a low energy level. Their temperament is described as melancholic. As inftants and young children they were characterized as fearful, sad, or withdrawn. In terms of body types they tend to have more endomorphic builds (Millon, 2011).

Psychologically, dependent personalities can be understood and appreciated in terms of individuals of their view of themselves, their world-view, and their life goal. The self-view of these individuals tends to be a variant of the theme: “I’m nice, but inadequate (or fragile).”

Their view of self is self-effacing, inept, and self-doubting. Their view of the world is some variant of the theme: “Others are here to take care of me, because I can’t do it for myself.” Their life goal is characterized by some variant of the theme: “Therefore, cling and rely on others at all cost.”

The social features of this personality disorder can be described in terms of parental, familial, and environmental factors. The dependent personality is most likely to be raised in a family in which parental overprotection is prominent. It is as if the parental injunction to the child is “I can’t trust you to do anyting right (or well).”

The dependent personality is likely to have been pampered and overprotedcted as a child. Contact with siblings and peers may engender feelings of unattractiveness, awkwardness, or competitive inadequacy, especially during the preadolescence and adolescent years. These can have a devastating impact on the individual, and further confirm the individual’s sense of self-deprecation and doubt.

This personality is reinforced and becomes self-perpetuating by a number of factors:

A sense of self-doubt
An avoidance of competitive activity
And particularly by the availability of self-reliant individuals who are willing to take care of and make decisions for the dependent person in exchange for the self-sacrificing and docile friendship of the dependent personality.

Treatment Considerations

The differential diagnoses for this personality disorder include the Histrionic Personality DisorderOpens in new window and the Avoidant Personality DisorderOpens in new window. Common diagnoses that are associated with the Dependent Personality Disorder include the Anxiety Disorders, particularly Simple and Social PhobiasOpens in new window, and Panic DisordersOpens in new window with or without AgoraphobiaOpens in new window.

Other common DSM-5 disorders include HypochondriasisOpens in new window, Conversion DisordersOpens in new window and Somatization DisordersOpens in new window. The experience of loss of a supportive person or relationship can lead to a number of affective disorders including Persistent Depressive Episodes. Finally, because dependent personalities can have lifelong training in assuming the “sick role,” they are especially prone to the Factitious DisordersOpens in new window.

In general, the long-range goal of psychotherapy with a dependent personality is to increase the individual’s sense of independence and ability to function interdependently. At other times, the therapist may need to settle for a more modest goal: that is, helping the individual become a “healthier’ dependent personality.

Treatment strategies typically include challenging the individual’s convictions or dysfunctional beliefs about personal inadequacy, and learning ways in which to increase assertiveness. A variety of methods can be used to increase self-reliance. Among these are providing the dependent person directives and opportunities for making decisions, being alone, and taking responsibility for his or her own well-being.

Specialties

Dependent Personality Disorder

Clinical Presentation

DSM-5 Characterization

Biopsychosocial – Adlerian Conceptualization

Treatment Considerations

See also: